Sustainable Financing for New Vaccines in Indonesia: Challenges and Strategies
2. Importance of Sustainable Financing for New Vaccines
2.1. Economic Evaluations of New Vaccines
2.2. Increasing National Revenue
2.3. Restructuring the Immunization System
3. Financial Barriers in Indonesia: Considering the Potential of COVID-19 Vaccine
3.1. Regional Disparities and Geographical Barriers
3.2. Lack of Infrastructure
3.3. Challenges in Vaccine Delivery
Conflicts of Interest
- WHO. Vaccines and Immunization. Available online: https://www.who.int/health-topics/vaccines-and-immunization#tab=tab_1 (accessed on 30 March 2020).
- Prüss-Üstün, A.; Corvalán, C. Preventing Disease through Healthy Environments: Towards an Estimate of the Environmental Burden of Disease; WHO: Geneva, Switzerland, 2006; pp. 65–70. [Google Scholar]
- WHO. Immunization, Vaccines, and Biologicals: The Middle-Income Country Strategy. Available online: http://www.who.int/immunization/programmes_systems/sustainability/mic_strategy/en/ (accessed on 24 December 2019).
- WHO. WHO’s Vision and Mission in Immunization and Vaccines 2015–2030. Available online: http://www.who.int/immunization/documents/general/WHO_Mission_VIsion_Immunization_Vaccines_2015_2030.pdf?ua=1 (accessed on 15 August 2019).
- WHO. Global Vaccine Action Plan 2011–2020. Available online: http://www.who.int/immunization/global_vaccine_action_plan/GVAP_doc_2011_2020/en/ (accessed on 19 August 2019).
- Committee on the Evaluation of Vaccine Purchase Financing in the United States and Board on Health Care Services. Financing Vaccines in the 21st Century: Assuring Access and Availability; The National Academies Press: Washington, DC, USA, 2004. [Google Scholar]
- WHO. Vaccine Market. Available online: http://www.who.int/immunization/programmes_systems/procurement/market/individual_vaccine/en/ (accessed on 30 March 2020).
- Immunization Financing. Indonesia: The Challenge of Protecting Immunization in the Transition to Universal Health Coverage. Available online: https://www.immunizationfinancing.org/en/country-case-studies/indonesia-the-challenge-of-protecting-immunization-in-the-transition-to-universal-health-coverage# (accessed on 30 March 2020).
- Gavi. Indonesia. Available online: https://www.gavi.org/programmes-impact/country-hub/south-east-asia/indonesia (accessed on 1 October 2020).
- WHO. Expanded Programme on Immunization of the Department of Immunization of the Department of Immunization, Vaccines and Biologicals, Vaccine Introduction Guidelines: Adding a Vaccine to a National Immunization Programme, Decision and Implementation; WHO: Geneva, Swizterland, 2005. [Google Scholar]
- DeRoeck, D.; Wang, A. Principles and Considerations for Adding a Vaccine to a National Immunization Programme: From Decision to Implementation and Monitoring; WHO: Geneva, Swizterland, 2014. [Google Scholar]
- Suwantika, A.A.; Postma, M.J. Effect of breastfeeding promotion interventions on cost-effectiveness of rotavirus immunization in Indonesia. BMC Public Health 2013, 13, 1106. [Google Scholar] [CrossRef] [PubMed][Green Version]
- Suwantika, A.A.; Zakiyah, N.; Lestari, K.; Postma, M.J. Accelerating the introduction of rotavirus immunization in Indonesia. Expert Rev. Vaccines 2014, 13, 463–472. [Google Scholar] [CrossRef] [PubMed][Green Version]
- Suwantika, A.A.; Zakiyah, N.; Kusuma, A.S.W.; Abdulah, R.; Postma, M.J. Impact of switch options on the economics of pneumococcal conjugate vaccine (PCV) introduction in Indonesia. Vaccines 2020, 8, 233. [Google Scholar] [CrossRef] [PubMed]
- Supadmi, W.; Suwantika, A.A.; Perwitasari, D.A.; Abdulah, R. Economic Evaluations of Dengue Vaccination in the Southeast Asia Region: Evidence from a Systematic Review. Value Health Reg. Issues 2019, 18, 132–144. [Google Scholar] [CrossRef] [PubMed][Green Version]
- Suwantika, A.A.; Kautsar, A.P.; Supadmi, W.; Zakiyah, N.; Abdulah, R.; Ali, M.; Postma, M.J. Cost-effectiveness of dengue vaccination in Indonesia: Considering integrated programs with wolbachia-infected mosquitos and health education. Int. J. Environ. Res. Public Health 2020, 17, 4217. [Google Scholar] [CrossRef] [PubMed]
- Suwantika, A.A.; Beutels, P.; Postma, M.J. Cost-effectiveness of hepatitis a vaccination in Indonesia. Hum. Vaccines Immunother. 2014, 10, 2342–2349. [Google Scholar] [CrossRef][Green Version]
- WHO. South-East Asia Regional Vaccine Action Plan 2016–2020. Available online: http://www.searo.who.int/indonesia/topics/immunization/south_east_asia_regional_vaccine_action_plan_2016_2020.pdf (accessed on 10 March 2020).
- Milken Institute. New Models for Financing Vaccination Programs in Southeast Asia. Available online: https://assets1c.milkeninstitute.org/assets/Publication/InnovationLab/PDF/VaxPrgrmsSEAsia4WEB.pdf (accessed on 10 March 2020).
- Results for Development. Immunizing Financing Options: A Resource Guide for Advocates, Policymakers, and Program Managers. Available online: https://www.gavi.org/sites/default/files/document/support/Immunization%20financing%20resource%20guide.pdf (accessed on 10 February 2020).
- Garner, P.; Flores, W.; Tang, S. Sector-wide approaches in developing countries: The aid given must make the most impact. BMJ 2000, 321, 129–130. [Google Scholar] [CrossRef]
- Immunization Financing. Bhutan: A National Trust Fund for Immunization. Available online: https://www.immunizationfinancing.org/en/country-case-studies/bhutan-a-national-trust-fund-for-immunization# (accessed on 10 February 2020).
- Sabin Vaccine Institute. Indonesia. Available online: https://www.sabin.org/programs/sustainable-immunization-financing/indonesia (accessed on 11 July 2020).
- WHO. State of Health Inequality: Indonesia; WHO: Geneva, Swizterland, 2017. [Google Scholar]
- World Bank. World Development Indicators. Available online: https://data.worldbank.org/indicator/SH.XPD.GHED.GD.ZS (accessed on 11 July 2020).
- Fang, P.; Dong, S.; Xiao, J.; Liu, C.; Feng, X.; Wang, Y. Regional inequality in health and its determinants: Evidence from China. Health Policy 2010, 94, 14–25. [Google Scholar] [CrossRef]
- Holzhacker, R.L.; Wittek, R.; Woltjer, J. (Eds.) Decentralization and Governance in Indonesia; Springer International Publishing: Cham, Swizterland, 2016. [Google Scholar]
- Heywood, P.; Harahap, N.P. Public funding of health at the district level in Indonesia after decentralization—Sources, flows and contradictions. Health Res. Policy Syst. 2009, 7, 5. [Google Scholar] [CrossRef][Green Version]
- Sparrow, R.; Budiyati, S.; Yumna, A.; Warda, N.; Suryahadi, A.; Bedi, A.S. Sub-national health care financing reforms in Indonesia. Health Policy Plan. 2017, 32, 91–101. [Google Scholar] [CrossRef] [PubMed][Green Version]
- Hodge, A.; Firth, S.; Jimenez-Soto, E.; Trisnantoro, L. Linkages between decentralisation and inequalities in neonatal health: Evidence from Indonesia. J. Dev. Stud. 2015, 51, 1634–1652. [Google Scholar] [CrossRef]
- Suparmi; Kusumawardani, N.; Nambiar, D.; Trihono; Hosseinpoor, A.R. Subnational regional inequality in the public health development index in Indonesia. Glob. Health Action 2018, 11 (Suppl. 1), 1500133. [Google Scholar] [CrossRef] [PubMed][Green Version]
- Statistics Indonesia. Life Expectancy. Available online: https://www.bps.go.id/linkTableDinamis/view/id/1114 (accessed on 1 October 2020).
- Statistics Indonesia. Percentage of Children 12–23 Months Who Received Complete Basic Immunization with the Lowest 40% Welfare Rate, by Province. Available online: https://www.bps.go.id/dynamictable/2019/10/04%2010:20:19.764125/1658/persentase-anak-umur-12-23-bulan-yang-menerima-imunisasi-dasar-lengkap-dengan-tingkat-kesejahteraan-40-terendah-menurut-provinsi-2015–2018.html (accessed on 25 August 2020).
- World Atlas. World Facts. Available online: https://www.worldatlas.com/articles/how-many-islands-does-indonesia-have.html (accessed on 19 February 2020).
- WHO. Cold Chain, Vaccines and Safe-Injection Equipment Management. Available online: https://www.who.int/immunization/documents/MLM_module1.pdf?ua=1 (accessed on 1 October 2020).
- Suwantika, A.A.; Boersma, C.; Postma, M.J. The potential impact of COVID-19 pandemic on the immunization performance in Indonesia. Expert Rev. Vaccines 2020, 19, 687–690. [Google Scholar] [PubMed]
- WHO. Framework for Decision-Making: Implementation of Mass Vaccination Campaigns in the Context of COVID-19. Available online: https://apps.who.int/iris/bitstream/handle/10665/332159/WHO-2019-nCoV-Framework_Mass_Vaccination-2020.1-eng.pdf?sequence=1&isAllowed=y (accessed on 1 October 2020).
- Gavi. Sustainable Development Goals. Available online: https://www.gavi.org/our-alliance/global-health-development/sustainable-development-goals (accessed on 1 October 2020).
- WHO. Exclusive Breastfeeding for Optimal Growth, Development and Health of Infants. Available online: http://www.who.int/elena/titles/exclusive_breastfeeding/en/ (accessed on 1 March 2020).
- WHO. Monitoring Progress in Averting Pneumonia and Diarrhoea Deaths. Available online: https://www.who.int/test/others/gappd/# (accessed on 1 October 2020).
- NCD Alliance. Breastfeeding—Transforming Global Health One Baby at a Time. Available online: https://ncdalliance.org/news-events/blog/breastfeeding-transforming-global-health-one-baby-at-a-time (accessed on 30 July 2020).
- Duijts, L.; Jaddoe, V.W.V.; Hofman, A.; Moll, H.A. Prolonged and exclusive breastfeeding reduces the risk of infectious diseases in infancy. Pediatrics 2010, 126, e18–e25. [Google Scholar] [CrossRef] [PubMed][Green Version]
- CDC. Water, Sanitation & Environmentally-Related Hygiene. Available online: https://www.cdc.gov/healthywater/hygiene/ldc/index.html (accessed on 24 June 2020).
- Unicef Indonesia. Water and Sanitation: Challenges. Available online: https://www.unicef.org/indonesia/wes.html (accessed on 24 June 2020).
- Unicef. Immunization Financing in MENA Middle Income Countries. Available online: https://www.unicef.org/mena/sites/unicef.org.mena/files/2018-04/immunization%20financing%20Web_0.pdf (accessed on 24 June 2020).
|General revenue from the central government||Central-level funding has the potential to promote self-sufficiency, a practice Indonesia must learn as it transitions away from Gavi assistance.||Since general revenue is controlled by the government, the amount of funds reallocated to immunization depends on political commitment.|
|Reallocating general revenue at the central government level to a national immunization program can decrease inequalities in funding across provinces.||There may be delays in the availability of central funds to the provincial level. This delay may cause some instability in the immunization program.|
|Sector-wide approach (SWAp) to financing||Donor contribution of funds to the entire health care sector based on the recipient country’s strategy will allow for the overall refinement of healthcare programs and increase its efficiency.||SWAp does not ensure that the funds will go directly to the immunization program to help finance new vaccines because the funding is not specific, but rather aimed to improve the entire health sector.|
|To increase self-sufficiency, this option provides an opportunity for the recipient country to build its economy to match the donor with domestic funds.||Another concern is that funding from donors may lead to dependence on external funding as opposed to promoting internal growth.|
|National trust fund||A trust fund can be detached from the unpredictability of the country’s politics and economy.||Building a sufficient fund can take time.|
|It can provide the flexibility needed in case of emergent outbreaks or other urgent situations.||A national trust fund for vaccines is a newer concept so there has not been a lot of experience with it.|
|Province block grant||A block grant promotes progress and equity as it provides sufficient financing to provinces based on their needs.||There is a chance that provinces may use grant money for other projects, especially during a period of financial distress.|
|A block grant also encourages innovation in techniques and approaches to optimize the subnational-level administration of vaccines.||If each province has its own system for handling immunizations, it may prove difficult to have efficient collaboration in case of an epidemic or pandemic.|
|Insurance mandate and subsidy||This solution may shift the government’s role from one of buying vaccines to one of assuring immunization by providing a fixed subsidy that is adequate to reimburse vaccination costs.||The cost required to ensure all populations are covered under an insurance mandate may result in increased payments for consumers in the form of taxes or other deductions.|
|This approach may take away some of the responsibility of local governments to manage the costs of vaccine.||This may result in referrals from private sector to public sector venues for immunization and may lead to shortages in vaccine availability in the public sector.|
|SDGs||Impact of Immunization on SDGs|
|(1) No poverty||Malnourished children are more likely to die from infectious diseases (i.e., diarrhea and pneumonia), which can be prevented by vaccines.|
|(2) Zero hunger||Immunization and good nutrition are inseparable. VPDs often tip marginally nourished children into a malnourished state.|
|(3) Good health and well-being||Immunization is one of the most cost-effective ways to save lives and promote good health and wellbeing. Vaccines save 2–3 million lives annually, and millions more are protected from disease and disability.|
|(4) Quality education||Immunization can increase educational attainment since vaccinated children learn more while they are able to go to school and perform better, making an impact on their cognitive development and long-term productivity.|
|(5) Gender equality||Girls and boys are targeted to be vaccinated at similar rates. However, there are variations in some countries because a range of different barriers inhibit women’s ability to access healthcare for their children.|
|(6) Clean and water sanitation||Clean water, sanitation, and hygiene (WASH) and vaccination are proven to be effective in preventing diarrheal diseases, a leading cause of child mortality in developing countries.|
|(7) Affordable and clean energy||Immunization can potentially bring more sustainable technology to develop countries’ healthcare systems, for instance vaccine monitoring devices with optimum energy usage and wastage reduction.|
|(8) Decent work and economic growth||Healthy children grow into a productive workforce and become strong contributors to the economy. Hence, investment in human capital can strengthen a country’s competitiveness.|
|(9) Industry, innovation, and infrastructure||Attractive vaccine markets can dramatically reduce vaccine prices and ensure more equitable and sustainable access to vaccines. More innovative products are required in the future to meet developing countries’ needs.|
|(10) Reduced inequalities||Vaccines can protect the health of communities, reduce the number of people forced into poverty, and make children healthier and more productive in the future.|
|(11) Sustainable cities and communities||Approximately 70% of the global population will be living in urban areas. Strengthening immunization programs is an opportunity to bring integrated preventative services to urban and underserved communities.|
|(13) Climate action||Immunization is critical to reduce the risk of outbreaks due to climate-sensitive diseases, such as yellow fever, cholera, and Ebola, particularly in urban, fragile, and post-disaster settings.|
|(16) Peace, justice, and strong institutions||Immunization is the first point of contact between the backbone of social institutions (i.e., effective, safe, and people-centered health systems) in every country and the population.|
|(17) Partnerships for the goals||An innovative public–private partnership model has transformed global progress by accelerating equitable and sustainable access to vaccines both at scale and pace.|
Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.
© 2020 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (http://creativecommons.org/licenses/by/4.0/).
Share and Cite
Fonjungo, F.; Banerjee, D.; Abdulah, R.; Diantini, A.; Kusuma, A.S.W.; Permana, M.Y.; Suwantika, A.A. Sustainable Financing for New Vaccines in Indonesia: Challenges and Strategies. Sustainability 2020, 12, 9265. https://doi.org/10.3390/su12219265
Fonjungo F, Banerjee D, Abdulah R, Diantini A, Kusuma ASW, Permana MY, Suwantika AA. Sustainable Financing for New Vaccines in Indonesia: Challenges and Strategies. Sustainability. 2020; 12(21):9265. https://doi.org/10.3390/su12219265Chicago/Turabian Style
Fonjungo, Fonette, Debabrata Banerjee, Rizky Abdulah, Ajeng Diantini, Arif S. W. Kusuma, Muhammad Y. Permana, and Auliya A. Suwantika. 2020. "Sustainable Financing for New Vaccines in Indonesia: Challenges and Strategies" Sustainability 12, no. 21: 9265. https://doi.org/10.3390/su12219265